Referrals between specialists in hospital outpatient departments.

There is little information on referrals between consultants (cross-referrals), and they are difficult to identify within current information systems which may affect the development of efficient services, and erode the traditional role of the general practitioner (GP) as the gatekeeper to secondary care. For one month in 1994, the source and outcome for all outpatient attendances was recorded in medical, paediatric and orthopaedic clinics in a teaching hospital and in a district general hospital. Detailed interviews were also held with consultants to increase understanding of reasons for cross-referral, and their appropriateness. Referrals from hospital doctors were more frequent in the teaching hospital and in the more specialised clinics. Cross-referral as an outcome of a clinic attendance was more common in the teaching hospital, and among patients seen in the general clinics. These findings support the view that cross-referrals are likely to increase as specialisation among consultants increases. Interviews with consultants showed that they did not believe that there was a need to reduce cross-referrals, which were regarded as an integral part of an effective service for patients. However, the development of GP fundholding may impose new constraints on specialists' ability to refer within the hospital system.